Violence Without Borders

From east to west, every emergency department seems to have similar concerns about violence against healthcare workers. No matter where we practice, we need to take a hard look at the factors – both institutional and cultural – that lead to unsafe working conditions.

The problem of emergency department (ED) violence is a worldwide issue, and a systematic approach to mitigating the threat to our colleagues and patients is fundamental to the advancement of emergency medicine (EM). Virtually every ED I have worked in or visited has identified security as a major concern.

As of this writing, I am leaving Qatar to return to Australia, and I have had the opportunity to reflect on some of the challenging issues that I dealt with in Doha and how much they have in common with EM in Australia and the rest of the world.

One of the biggest challenges that I faced in the first few weeks of arriving in Doha was when one of my doctors was seriously physically assaulted in an unprovoked attack by a patient’s relative, resulting in hospital admission. Fortunately, he recovered physically, but his mental trauma, and the repercussions of the assault on the workplace and his colleagues, was significant. This was not an isolated event and certainly not a problem restricted to the ED. As a result of the assault, an organization-wide review of security was undertaken, specifically focused on EM and what could be done to mitigate the risk to staff and patients.

In basic terms, there are three groups of attendees that may cause a physical risk to staff in the ED. The first is patients who are psychiatrically ill or intoxicated with stimulant/disinhibiting drugs; the second is relatives who are angry/demanding about treatment management (who may also be intoxicated); and the third is patients or relatives with malicious intent, either to staff or patients—often in the setting of war, civil unrest, or gang violence (the third group was not really an issue in Qatar).

The approach that we took was to look at the physical structure of the ED and review entry/exit to key areas with swipe card access and security guards. Limiting relatives and unnecessary movement within the ED was difficult, given the cultural necessity of allowing large families access to seriously ill relatives. In an overcrowded department with no space for relatives or patients to wait, controlling movement is even more problematic, although getting some control certainly helps. Improving the flow of patients and relatives also assists with frustrations from the public.

A major area of focus is retraining clinical staff on how to defuse and de-escalate potentially volatile situations. This is probably the most effective intervention that we undertook in reducing the threat to staff.

An important consideration was video monitoring of all public areas. This was a major improvement that had a definite effect on behavior. Because of privacy concerns, we could not review patient treatment bays. Access to video review of incidents not only resulted in immediate resolution of many incidents but it also had a real time deterrent effect.

Security training was poor and guards were not empowered to restrain individuals without fear of an assault charge (and prison sentence) under Qatari law. Therefore, the ability of security to restrict a determined individual with malicious intent was (and still is) limited. A great deal of training and better liaison between security and clinical staff has helped, but this remains an issue. At minimum, security staff must be trained in de-escalation techniques, how to recognize certain behaviors associated with alcohol and drugs, and how to restrain agitated patients safely.

A major area of focus was to retrain clinical staff on how to defuse and de-escalate potentially volatile situations. This is a neglected area of clinical training, but an obvious intervention, and probably the most effective intervention that we undertook in reducing the threat to staff. A confident, calm, and reassuring staff member, backed up by colleagues, can defuse most situations. It is important to remember that with staff turnover, rotations, and so on, this is a continuing challenge. All staff have undergone compulsory one-day training, with more advanced training for clinical leaders.

Public awareness of the issue is important but difficult, and it can backfire in the sense that the public may take broad based messaging the wrong way. To the worst elements of the public it might be seen as a “challenge” to beat increased security, and to the better behaved groups it might be seen as an insult. The messaging must therefore be subtle and targeted. Clearly, the public has to know that certain behavior will not be tolerated in the clinical areas—in much the same way that airports require a restrictive approach. Signage and consistent staff behavior with regard to access are important.

The issue of metal detectors, screening of relatives on entry, and so on was discussed, but the possibility of actually escalating conflict is high. The hospital is a community facility and families come there for help and compassion. It is not a military or high security area, and families should not be intimidated by high-level security arrangements. For aggressive and agitated patients, it is likely that violence would be increased by such interventions.

Personal distress alarms, staff position monitoring, and other electronic tracking devices have been partially implemented. The physical layout of the current department makes centralized control difficult, but this will become easier with a new facility. An immediate security response across the whole ED is the eventual aim.

I do not believe that we can have a 'zero tolerance' approach without making things worse.

With about 100 individual interventions and a corporate approach, security has improved tremendously. There is still much work to do and staff still do not feel totally secure in the ED. In reality there have been no further serious injuries subsequent to this sentinel event.

A continuing issue is low-level verbal abuse and physical intimidation. Much of this is expected with agitated patients who may be intoxicated, psychologically disturbed, or simply frustrated. All staff working in the ED must expect to manage this as part of their work. In addition, they must be formally trained in de-escalation techniques. I do not believe that we can have a “zero tolerance” approach without making things worse. The issue that makes most staff anxious is: what happens when things go wrong and verbal abuse becomes physical abuse? A guaranteed and structured response is necessary to allay staff fears.

The level of violence in EDs varies around the world. Obviously, in war torn countries with civil disruption, violence is common. There are also many inner city EDs in the US and other countries where drugs and street gangs threaten staff and patients. For most EDs in developed countries, serious physical violence resulting in injury is uncommon, but low level intimidation and verbal abuse is very common. ED staff and patients must turn up to work and feel confident that should a real threat emerge there will be a safe response. Unfortunately, a sentinel event is often required in order for hospitals to take a systematic approach to the issue.

The International Federation for Emergency Medicine is in an ideal position to promote discussion on this topic and to develop best practice models that are sensitive to local context. Accordingly, I am hopeful that this will be a topic for discussion at the 2016 ICEM in Cape Town.

Dr. Peter Cameron is the immediate past president of the International Federation for Emergency Medicine (IFEM)